Safe to
wander?
Principles and guidance
on good practice when
considering the use of
wandering technologies
for people with dementia
and related disorders
Contents
Why have we prepared this guidance?
1
What do we mean by ‘wandering
technology’ and why is it an issue?
2
General principles in considering
the use of new technologies
4
Considering the use of wandering
technology: assessment and care planning
5
Physical assessment
5
Psychological assessment
6
Assessment of risk
7
Alternatives to wandering technology
7
The care plan
8
Consulting with the Care Commission
8
Important legal considerations
9
Summary and good practice checklist
10
Checklist
11
Bibliography
12
Acknowledgements
12
1
Why have we prepared
this guidance?
The Commission has an
active role in ensuring that
individuals have access
to care which is most
appropriate to their
individuality, their unique
care needs and their human
rights. We are often asked
about restraint and restrictions
placed on individuals in
mental health, learning
disability and older people’s
services. In response to these
we produced ‘Rights, risks
and limits to freedom’ which
sets out our views on the law
and good practice in this
area of practice. In addition
to questions on the broader
issues, the Mental Welfare
Commission is occasionally
asked for advice on the use
of technology in caring for
people with dementia,
learning disabilities and
related disorders. Our
response is generally that
we believe that technology
can be a valuable tool
which has the potential to
help people to maintain their
independence and enhance
their freedom and that,
where new technology
can provide assistance
without unduly restricting
or increasing the risks that
an individual may face,
its use is to be welcomed.
This publication provides
more specific guidance
for those considering the
use of new technologies,
particularly in support of
individuals with dementia
who are resident in
care homes or hospitals.
Although we focus on
dementia and residential
care, the principles of this
guidance may also prove
helpful for people working to
provide care and treatment
for other mental disorders
in a range of settings,
especially as the use of
emerging technologies
evolves to provide home
based alternatives
residential care.
The Commission are not
the only source of advice
in this area, guidance for
staff working in Scotland
has also been prepared by
National Care Standards
Committee and staff will
also be supported by
policy and procedures
guidance prepared within
their own services.
2
Those considering
the use of wandering
technologies have to be
aware of the potential for
this to constitute restraint.
What do we mean by
‘wandering technology’
and why is it an issue?
bad and that the person
should be able to walk freely
and safely.
• Electronic tagging and
tracking systems
The term ‘wandering’ can
have negative connotations.
For the individual concerned
however ‘wandering’ is
usually a positive experience
which can provide physical
and psychological benefits.
The Commission recognises
that this term is often
mistakenly used to describe
a wide number of differing
types of behaviour and can
be considered unhelpful,
particularly in relation to
people with a learning
disability. After a long debate
however, we have decided to
refer to ‘wandering’ in this
document as it remains,
rightly or wrongly, the term
most commonly used in
dementia care settings.
In ‘Rights, risks and limits
to freedom’ the Commission
set out its definition of
restraint. ‘restraint is taking
place when the planned or
unplanned, conscious or
unconscious actions of care
staff prevent a resident or
patient from doing what he
or she wishes to do and as
a result is placing limits on
his or her freedom.’ Based
on this definition, those
considering the use of
wandering technologies
clearly have to be aware of
the potential for their practice
to constitute restraint and to
take this into account in their
decision making.
• Intruder alerts
‘Wandering’ sometimes
suggests aimless walking.
This is sometimes the case,
but it is more likely that the
behaviour has meaning for
the person with dementia.
It is important to try to
understand where the
person is trying to go and
to recognise that walking to
destinations of interest will
be of benefit to the person.
We need to recognise that
‘wandering’ is not necessarily
There are many examples of
the creative use of technology
to support safe movement
in care homes and hospitals
and technology is increasingly
being used in individuals’
own homes. Wandering
technology that can be put
in place could include:
• Sensor pads
(beds, chair, floor)
• Nurse/carer call systems
• Panic buttons
• Fall and movement sensors
• CCTV/video surveillance
This document will focus
exclusively on the use of
‘tagging’ and tracking
devices. The term tagging
is often associated with
criminal activity and
surveillance, shopping
and the prevention of crime.
It can involve the use of
satellite technology to alert
the police or probation
services that a person is in
breach of parole conditions
or a curfew. The use of
electronic tagging in this
document is only in relation
to care settings and has
no criminal component.
To avoid confusion, the term
‘wandering technologies’ will
be used in this document,
nevertheless those
considering its use should
still be sensitive to the
perceptions that service
users, carers and staff may
have of the technology.
The use of wandering
technology is primarily
used for individuals who are
considered to be at risk from
leaving a care environment
unescorted. It mainly
involves the use of boundary
3
crossing alarms whereby
a member of the care staff
is alerted when an individual
crosses a pre-designated
boundary. The alarm alerts
care staff that an individual
resident is possibly at risk
of leaving, though the system
itself does not prevent them
from doing so. Wandering
technology also includes
the use of tracking devices
which can locate the wearer
if he/she becomes lost or
fails to return. Tracking
devices are currently rarely
used in this country for
individuals in care home
settings but the technology
is now becoming increasingly
easily available and financially
affordable. Tracking devices,
using global positioning
system satellite technology,
are currently being used
in Spain for some patients
with Alzheimer’s disease.
Small electronic devices are
attached to the individual’s
clothing and they emit a
signal which can be traced
if the individual strays from
a previously designated area.
New technology may provide
a less restrictive or more
beneficial care option than
other ways of managing
an individual who wanders.
A survey in 1998 suggested
that up to 40% of individuals
with dementia become lost
at some point during their
illness and 5% get lost
repeatedly over many
months. Over 70% of those
who get repeatedly lost are
admitted into institutional
care as a means to manage
the risks of their illness.
Many care establishments
are locked or have barriers
such as keypads or handle
arrangements that require
some skill to open. Such
barriers can then restrict
the free movement
of all residents of the
establishment, regardless
of whether they are at risk
from wandering.
For those individuals
already in residential care,
wandering behaviour may
increase, or pose a particular
risk to an individual, who
may as a result be moved to
a more secure environment.
This can prove unsettling
for the resident and for
carers. Where the use of
technology can play a part
in maintaining independence,
or enabling continuity of
care, we think it should be
considered.
It is also worth recognising
that physical activity maintains
and improves general health
and reduces the risk of
falling in the elderly. People
with dementia who have the
freedom to wander receive
positive health benefits from
their activity and wandering
technologies could have
a part to play in promoting
individual health and
wellbeing.
4
On no account should
technology be used
merely to save on the
cost of appropriate
staffing.
General principles
in considering the use
of new technologies
The intervention must
provide a benefit that cannot
otherwise be achieved
The key to best management
of wandering behaviour is to
allow the person to walk freely
and to destinations of interest
without subjecting the person
to unnecessary or causing
unnecessary distress. The
use of technology may
contribute to this, but only in
conjunction with good design
of the living environment,
stimulation, meaningful
activity and appropriately
trained care-givers.
What will the benefit of
the technology be to the
individual? If used
appropriately the benefit
may be improved personal
safety, increased dignity,
independence and sense
of freedom. It may reduce
the need for obtrusive levels
of observation that could be
distressing for the individual.
A person for whom the use
of wandering technology
is being considered is likely
to lack capacity in relation
to decisions about its use,
although this should not be
assumed. Where capacity
is lacking, it is important that
the principles of the Adults
with Incapacity (Scotland)
Act 2000 are applied in
decision making:
There might be drawbacks to
the use of such technology.
Apart from unnecessary
restriction of freedom,
(see below) it may provide
a false sense of security.
The person may travel within
an apparently safe area but
may not be alert to significant
risks within that area. Also,
the person may leave the
safe area and suffer harm
before care-givers can
respond to an alert. The
use of new technology may
reduce personal contact
with care-givers and this is
unlikely to benefit the person.
Technology is no substitute
for appropriate levels of
personal care and human
interaction. On no account
should technology be used
merely to save on the cost
of appropriate staffing.
The intervention must be the
least restrictive in relation to
the person’s freedom in order
to achieve the desired benefit
Will the technology result
in the least restriction
consistent with the person’s
dignity, safety and
independence? There is
likely to be a tension
between protection and
safety, versus privacy and
dignity. Technology may
allow the person more
freedom than locking doors
or having a member of staff
watch the person at all times.
However if the person often
has to be retrieved and
returned to the place of
residence, it may result
in increased distress or
public ridicule.
The past and present wishes
of the person must be taken
into account
Care-givers should not
assume that the person
lacks capacity in relation
to wandering technology.
People whose cognitive ability
fluctuates may be capable of
stating their wishes to be safe
during periods of increased
confusion and can participate
fully in decisions. Even when
the person appears to lack
capacity, care-givers must
make every effort possible
5
to discuss such risks and to
help the person to understand
the benefits of technology
solutions. Care-givers should
make a careful record of
such discussions including
whether the person agrees
or disagrees with the use
of technology. This must be
approached with sensitivity
and only after the person has
had time to come to terms
with his or her diagnosis
and its implications.
The views of relevant others
should be taken into account
A wide range of people will
have valuable roles to play
in the decision on whether
to use wandering technology,
including:
• Nearest and close relatives
and friends will know
the person best and
can provide valuable
information about his/her
life. This may be crucial in
understanding the person’s
behaviour. They will also
have views about risks and
dignity and these should
be taken into account.
• A welfare attorney or
guardian with powers
over the person’s welfare
may have the authority
to consent to the use
of wandering technology.
Even where a specific
power is not included in
these granted these may
include decisions on
the person’s place of
residence, which may be
affected by the potential
use of technology. In such
cases it is important to
consult such a person on
the use of technology.
• Professional carers will
have experience in
managing wandering
behaviour, in particular their
advice on environmental
design or modifications
and assessment of risk
will aid the decision
making process.
The intervention should
encourage the person to use
existing skills and develop
new ones
This principle is to be
observed by attorneys,
guardians and managers
of care establishments,
and represents good practice
for anyone involved in the
person’s care. If the use
of technology to manage
wandering behaviour
increases the opportunity
for the person to use existing
skills and to develop new
ones, then it merits serious
consideration.
Considering the use of
wandering technology:
assessment and care
planning
Prior to introducing any
wandering technology
system there should be
careful physical and
psychological assessment
to eliminate any reversible
cause of the wandering
behaviour. This assessment
would involve analysing what
is actually happening, when
it is happening, what triggers
the behaviour and what
intervention helps.
• Physical assessment
Any physical assessments
should be multi-disciplinary
and should include:
Medication review
Many medications for both
physical and psychiatric
conditions have side-effects
which can include motor
restlessness, confusion and
constipation amongst others.
All of these side-effects
can contribute to the
development of worsening
wandering behaviour and
medications should be
regularly reviewed by the
medical practitioner
(particularly those supplied
for the treatment of anxiety,
depression and insomnia).
6
Elimination
Constipation or urinary
discomfort can lead to
restlessness and should
be addressed. Searching for
a toilet and worries about
incontinence can also be
an issue. Toilets should be
clearly identified.
Pain assessment
Some people with dementia
are not able to express their
pain, which can manifest as
restlessness or increased
confusion. The physical
exercise that wandering
provides may prevent pain
developing, or provide a form
of pain relief in itself. Early
pressure sore development
can cause extreme pain with
no obvious visible injury.
Other factors for consideration
Deterioration in hearing or
vision can lead to
restlessness and increased
confusion. It is extremely
important that these are
assessed regularly and that
spectacle and hearing aids
are well maintained and
available.
A person may be wandering
because he or she is too
hot or too cold and is trying
to find a more comfortable
environment. Hunger and
thirst may also be a factor.
A poor sleep pattern can
contribute to wandering
behaviours and it is well
known that infection can
increase confusion and
restlessness. These
potential causes should
be investigated quickly
and treated appropriately.
• Psychological
assessment
Identification of the
purpose of walking
Understanding what the
person is trying to achieve
is critical to successful
management of wandering
behaviour. The person may
believe that he or she has
to go somewhere or
something to do. Most likely,
this will involve tasks from
the person’s past that he or
she believes are necessary
in the present. Examples
would be going to work or
getting the family’s dinner
ready. The person may
believe that he or she lives
at a former address and
may be attempting to go
there. Life-story books and
information from relatives
and friends can provide
knowledge of his or her
life history that may be very
helpful in understanding the
person’s present behaviour.
Wandering as communication
of distress
Wandering may be occurring
simply because the person
is bored and unstimulated
in his or her environment.
The person may not have
a peer group he or she can
relate to, or feel cut off from
his or her family and friends.
These issues this would
need to be fully addressed
in an individual care plan.
Depression is very common
among people with dementia
and can require specialist
input with regard to diagnosis
and treatment. Depression
can lead to anxiety which
produces restlessness and
an inability to initiate
meaningful activities.
Wandering may also be
caused by feelings of
fearfulness. The person may
be afraid of particular aspects
of his or her environment,
for example uncontrolled
noise levels or individual
phobias. Psychological
assessment should also
consider if there is any
evidence of hallucinations,
delusions or delirium as these
can be extremely frightening
for the individual.
7
Assessment of risk
Any assessment must include
analysis of the risk that is
being presented. This must
focus on the risk to the
individual, not the organisation
or care facility. Assessment
should always take the views
of the individual, formal carers
and involved relatives into
account. There should be a
careful evaluation of the risk
that is presented and the
likelihood of that occurring.
The risk to the individual of
any proposed intervention
should also be discussed
and this would include
psychological as well as
physical safety concerns.
Care establishments should
have written policies on care
planning and risk assessment
that take into account the
person’s need to exercise
and move freely.
Alternatives to wandering
technology
Before considering the use
of wandering technology
there should be an appraisal
of the interventions that
have been tried to date.
This should form part of
the assessment process.
People with dementia need
appropriate stimulation and
activity. Individual care plans
must reflect this and will
benefit from input from a
skilled occupational
therapist. A person with
dementia who finds him or
herself in an understimulating environment, may
well explore in an attempt to
find something more
interesting or meaningful to
do. It would be wholly
inappropriate to use a
technology solution for this
behaviour, unless great
attention is paid to
appropriate, person centred
occupation and stimulation.
The importance of dementiafriendly design, including the
creative use of outdoor
space should not be
underestimated although
there will obviously be
physical limitations in older,
non-purpose built units.
Ideally, buildings should
provide open access to safe
outdoor space. The internal
environment must contain
destinations that are of
interest. Long corridors
leading to locked exit doors
must be avoided.
Small changes in practice
and environments can have
successful outcomes. The
importance of exercise
should be taken into account
and incorporated into the care
plan as appropriate.
The use of cloth panels to
conceal doors or door knobs
(which can be described as
‘subjective barriers’ to
wandering in that they
appear as an obstruction only
to those who are cognitively
impaired) could offer a less
restrictive option than a
locked door.
Another alternative to
wandering technology
is the adaptation of nursing
observation policies to meet
the needs of the individual
flexibly and when most
necessary. Many individuals
require increased levels of
observation only at particular
times of day and night,
rather than having fixed
observation levels.
8
The care plan
Following individual
assessment, any factors
identified can be addressed
in his or her care plan. If a
decision is taken to introduce
wandering technology then
a specific care plan relating
to its use should be drawn up.
This care plan should address:
Involvement of the individual
and relevant others
Consulting with the
Care Commission
There must be a clear verbal
explanation of the system
give to the individual,
relatives, visitors and
advocacy workers. It would
be good practice to provide
written information about
the system.
It is of vital importance that
managers of care homes
consult with the Care
Commission if considering the
use of wandering technology.
Under the Regulation of
Care (Requirement as to
Care Services) (Scotland)
regulations 2002, 19 (3),
‘A provider shall keep a
record of: any occasion on
which restraint or control ha
been applied to a user, with
details of the form of restraint
or control, the reason why it
was necessary and the name
of the person authorising it’.
How the technology works?
Monitoring
There should be clear,
explicit instructions for
staff about how the system
works and training in
the use of the system,
including maintenance
and contingency plans in
the event of malfunction.
Training should be viewed
as an ongoing need, not
a one-off occurrence.
It will be extremely important
to monitor how well, or not,
the system is working. This
should include reports of
how often the system is being
triggered and the individual’s
reaction to it. It will be
important to monitor if there
has been a change in the
individual’s general wellbeing.
The plan will include
definition of which areas
are considered safe for the
individual and which are
not. There must be clear
identification of who will
respond to the alarm and
when, of what should
happen if the individual
refuses to return. This may
involve external agencies
such as the police. The
police will need to be
consulted if they may
be required to respond.
Regular review dates should
be set and all involved
professionals and caregivers, both informal and
formal, should be invited
to the review. It would be
best practice for the key
worker/named nurse and
unit manager to be present.
There should be an identified
senior manager who receives
copies of the reviews. The
primary purpose of the
review is to consider
whether ongoing use of the
system is indicated or not.
Review
9
Important legal
considerations
As outlined in the section
on general principles, the
Adults with Incapacity Act
must guide the process of
deciding on the use of
wandering technology. This
section examines the impact
of specific principles of this
Act, the principles of the
Human Rights Act and the
provisions of the Mental
Health (Care & Treatment)
(Scotland) Act 2003.
Human Rights Act
The legal rights of the
individual have become
increasingly significant with
the introduction of the
European Convention on
Human Rights into UK Law.
Articles 3,5 and 8 could be
of particular relevance to
those considering the use
of wandering technologies. In
developing this guidance we
feel it is particularly important
to emphasise Article 5 of
the Convention; ‘Everyone
has the right to liberty and
security of person. No one
shall be deprived of his liberty
save in the following cases
and in accordance with a
procedure prescribed by law.’
One of the cases is ‘the
lawful detention of persons
of unsound mind’. The
European Court has ruled
that failure to follow legal
procedures to detain a person
in hospital for treatment of
mental disorder was unlawful.
This ruling has implications
for the management of
people with dementia or other
mental disorders who wander.
In addition, Human Rights
law says that the person
must not be subject to
degrading treatment and has
a right to privacy. Any
decision to use technology
must be consistent with
these principles. In practice,
attention to the principles
of the Adults with Incapacity
Act will be likely to result
in compliance with Human
Rights law.
Specific measures under
the Adults with Incapacity
Scotland Act
Incapacity legislation
makes several provisions for
delegation of decision making
for people lacking capacity.
A person, while capable,
may appoint a Welfare Power
of Attorney to take decisions
on his or her behalf once
capacity is lost. Welfare
Guardians can be appointed
by the court to make
decisions on behalf of an
adult who lacks capacity. The
views of Welfare Attorneys
and Guardians must always
be considered when making
a welfare decision. If specified
in the powers granted, the
Attorney/Guardian may have
the authority to decide on the
use of technology. Hospital
and care home managers
should be aware of the extent
of the Attorney’s powers
and may need to seek legal
clarification on this.
If there is no Attorney or
Guardian with the authority
to make decisions about
technology, anyone faced
with a decision about the use
of wandering technology will
need to consider whether to
seek a Guardianship order
under part 6 of this Act. If
the intervention is necessary,
and if the person lacks
capacity in relation to this
decision, it can be argued
that Guardianship is
necessary.
The Commission takes the
view that, where a person
demonstrates a purposeful
desire to leave his or
her place of residence
a Welfare Guardian should
be appointed should it be
necessary to restrict the
person’s movements. Where
wandering behaviour is more
aimless, the legal situation
is less clear and it can be
10
New technology is no
substitute for human
and compassionate
care.
argued that Guardianship
is unnecessary and too
restrictive.
Summary and good
practice checklist
Good practice guidance
on the use of the Adults
with Incapacity Scotland
Act is available from the
Commission’s website
www.mwcscot.org.uk.
Mental Health (Care
& Treatment) (Scotland)
Act 2003
This Act authorises detention
in hospital and the use of
wandering technology could
be regarded as treatment
for mental disorder under
this Act. Mental health law
can authorise compulsory
measures to ensure
treatment outside hospital,
this may also include
wandering technology. It is,
however, unlikely that this
type of legislation would be
appropriate for people not
already liable to compulsory
measures for other reasons.
All technologies, including
wandering technologies,
have the potential for abuse if
not used within a proper legal
framework and with reference
to good practice guidance.
Where such technology is
used, great care must be
taken to ensure that the
person concerned has his
or her rights protected. It is
possible to see the potential
benefits of wandering
technology for the individual
in some cases, but this
should never stigmatise the
individual and should never
replace direct contact with
care-givers. New technology
is no substitute for human
and compassionate care.
It is acknowledged how
difficult it can be for care staff
to provide a balance between
the autonomy of the individual
and the duty of care owed to
that person by the care home
or hospital staff. By placing
limits on the individual’s
ability to leave the care
setting, there could actually
be an opportunity to offer a
less restrictive environment
and this apparent tension
can cause dilemmas for
staff and relatives.
The use of technology,
including wandering
technology, in care homes
and hospitals is not in itself
a good or a bad thing.
Where technology is used,
this should be as a tailored
and appropriate response
to the identified risks faced
by an individual. How
technology is applied can
make the difference between
providing restrictive and
inflexible care, or a freedom
enhancing setting.
11
Checklist
Consider causes of behaviour
Assess the risks to the individual
Consider alternatives to use of technology
Identify if wandering technology is available and appropriate
Ascertain views of individual, relatives, care team, Care Commission etc
Consider ethical implications, the benefits and disadvantages of the system
Consider legal implications for individual, in particular the possible use
of Adults with Incapacity (Scotland) Act 2000
Formulate individual care plan
Ensure all staff and involved relatives understand care plan
Monitor implementation of care plan
Review care plan frequently
12
Bibliography
Legislation
Adults with Incapacity
(Scotland) Act 2000,
HMSO, Edinburgh, 2000.
Human Rights Act 1998,
HMSO, 1998.
Mental Health (Care
& Treatment) (Scotland)
Act 2003, HMSO, 2003.
European Court of Human
Rights: HL v the United
Kingdom (application
no.45508/99).
Other
Alzheimer’s Society –
the Society’s position on
electronic tagging is available
at www.alzheimers.org.uk.
Bosch, X. Spain plans
electronic tagging for
patients with Alzheimer’s
Disease, The Lancet,
Volume 355 (9208).
Kirkwood, T. Dementia
Rediscovered, Buckingham:
Open University Press 1997.
Klein, D. Steinberg, M.
Wandering Behaviour
in Community Residing
Persons with Dementia,
International Journal
of Geriatric Psychiatry,
Volume 14, 1999 pp 272.
McShane et al. Tracking
patients who wander: ethics
and technology, The Lancet,
Volume 343 (8908) May 1994
pp1274.
Mental Welfare Commission
for Scotland, Rights, risks
and limits to freedom, 2006.
Patrick, H. When to invoke
the Adults with Incapacity Act,
Mental Welfare Commission
for Scotland, 2005.
Patrick, H. Authorising
significant interventions for
people who lack capacity,
Mental Welfare Commission
for Scotland, 2004.
Price, JD. Herman DG.
Cochrane Database
of Systematic Reviews,
Subjective Barriers
to Prevent Wandering
of Cognitively Impaired
People, Issue 3, 2001.
Values into Action, “Tagging:
A technology for care
services?”, 1998.
Acknowledgements
We wish to thank all who gave
advice on the content of this
document during the various
stages of its development.
In particular we wish to thank:
• Alzheimer’s Scotland
• Association of Directors
of Social Work
• Care Commission
• Dementia Services
Development Centre,
University of Stirling
• Glasgow Dementia
Working Group
• Royal College of
Psychiatrists, Scottish
Division
• Royal College of Nursing,
Scotland
• West Lothian Council
Thistle House
91 Haymarket Terrace
Edinburgh
EH12 5HE
Tel: 0131 313 8777
Fax: 0131 313 8778
Service user and carer
freephone: 0800 389 6809
[email protected]
www.mwcscot.org.uk
July 2007